CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 604 667.250000 24688.2500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 313 403.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 142 239.750000 8870.7500 37.0000
Subtotal (Total Children Is Unduplicated) 651 1310.000000 33559.0000 25.6176
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 33 41.750000 2087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 58.000000 4350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 59.500000 3302.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 27.500000 2062.5000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 3.000000 138.1500 46.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 90 229.750000 14661.9000 63.8168
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 1279.4400 319.8600
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 40.500000 2025.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 121 104.000000 5200.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 3 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 10.000000 500.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 74 54.500000 2725.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 77 349.750000 17487.5000 50.0000
INTR-T1013-INTERPRETER 11 43.250000 2162.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 406 2618.000000 26103.5600 9.9708
OCCT-97530-OT SESSION BY LICENSED OT 27 164.000000 11155.6600 68.0223
PHY-97110-PT SESSION BY LICENSED PT 35 162.750000 9703.7500 59.6237
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 536.250000 38139.6000 71.1228
TRAV-TRAVS-Travel by mile 275 14802.00000 6576.2000 0.4443
Subtotal (Total Children Is Unduplicated) 593 18890.50000 123095.7100 6.5163
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Total 20430.250000 171316.6100 8.3854
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Number of Children (Unduplicated) With at Least One Service 873
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Center 02
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4342 12609.750000 116327.3700 116195.2300
224 411.500000 7410.1900 0.0000
Other 2776 7409.000000 47579.0500 0.0000
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Total 7342 20430.250000 171316.6100 116195.2300